Table 3.

Compilation of Our Recommended Reforms of the IHR and Their Implementation

	Recommended
	Reform	Who and Why	Political Mechanism
IHR Core Capacities	Secure national and global commitment to build, strengthen, and maintain IHR core capacities linked directly to independent assessments and financing.	Who: National governments, international organizations, bilateral donors, and funding organizations Why: Global health security is dependent on every nation having the ability to detect, assess, report, and respond to public health emergencies.	No textual change to IHR required for commitment to core capacities Political and financial commitment to support process required by the WHO and other funding entities, such as the World Bank and regional development banks
Independently Assessed Metrics	Utilize rigorous metrics assessed by independent evaluators to identify capacity gaps, develop a road map, and identify funding sources to achieve core capacities.	Who: Independent evaluation teams of domestic and external experts with the participation of the WHO, regional and country offices, and civil society Why: Independently assessed, vigorous metrics will provide accurate analysis of national core capacities that can then be used by funding entities to invest in core capacities or for use in insurance mechanisms.	Amendment of Annex 1 of IHR to include measurable benchmarks Tasking the WHO to work with funding entities to create rigorous metrics and organize assessments
Harmonization	Harmonize independent assessments and metrics with the GHSA and the OIE's PVS Pathways.	Who: The WHO in collaboration with the GHSA and the OIE Why: Harmonization will ensure a One Health strategy and reduce redundancies for governments exposed to multiple evaluations.	Harmonization incorporated into Annex 1 amendment WHO, GHSA, and OIE enhanced communication and collaboration
New Financing Mechanisms	Obtain robust financing to build core capacities as well as to support the WHO's capacity (including surge capacity in emergencies) and to build human resources.	Who: WHO Member States, the World Bank PEF, the GHSA, the WHO Contingency Fund, and the WHO Global Health Reserve Workforce, including the Global Outbreak Alert and Response Network Why: Core capacities cannot be built or sustained without reliable funding. For funding agencies, the return on investment for building core capacities (as opposed to experiencing a large‐scale, uncontrolled outbreak) is significant.	Existing IHR text under Article 44 Increase in WHO Member States–assessed contributions GHSA Action Packages in support of IHR implementation, World Bank PEF, and/or raising resources support through donors’ conferences modeled on the Global Fund
Workforce Development	Create national assessments and career plans for a robust clinical and public health workforce and commit to developing and maintaining the workforce. Build an international emergency workforce ready to respond when national systems are overwhelmed.	Who: National governments with international funding and assistance and WHO coordination for emergency workforce Why: Achieving IHR core capacities, and universal health coverage in general, will require developing (and sustaining) a well‐trained, well‐equipped national workforce. In times of emergency, when even a well‐prepared workforce cannot cope, the international community must provide surge capacity.	Domestic workforce supported through national commitment and assessment with funding assistance from the WHO, the World Bank, and other funding agencies WHO commitment to GOARN, the Global Health Reserve Workforce, and foreign medical teams, including major civil society organizations such as Médecins Sans Frontières
Emergency Committee Transparency	Ensure independent and transparent Emergency Committee decision making, supported by civil society shadow reporting.	Who: The WHO in collaboration with civil society Why: Independent and transparent Emergency Committees will build public trust.	Administrative action by WHO
Tiered PHEIC Process for Early Action	Institute a tiered process for declarations of a PHEIC. Harmonize diverse WHO global alert frameworks with the IHR.	Who: The WHO Why: A tiered PHEIC declaration process would allow for formal action prior to a full declaration. It could also trigger clear operational and financial strategies, such as access to the Contingency Fund.	WHO development of informal guidelines through Article 11 with WHA understanding or WHA adoption of a new IHR annex illustrating the risk gradient without opening the full text for negotiation
Enhanced Compliance	Enhance IHR compliance through a series of carrots and sticks to encourage development of core capacities and to keep Member States from taking action inconsistent with the Emergency Committee travel and trade recommendations.	Who: The WHO in consultation with other arbitration bodies such as the WTO, the FAO, and the ICJ Why: States Parties’ disregard for travel and trade recommendations and insufficient devotion of resources to building core capacity undermine the IHR and weaken global health security.	Public request by the WHO for clear rationales from States Parties that take additional measures outside Emergency Committee recommendations Active pursuit of dispute mediation and arbitration under the IHR, use of the Permanent Court of Arbitration Optional Rules for Arbitrating Disputes, and encouragement of challenges through the World Trade Organization or the International Court of Justice WHA amendment of the IHR to elevate temporary recommendations to a binding status
Role of Civil Society Organizations (CSOs)	Engage civil society in IHR governance and implementation activities, including shadow reports, inputs to the Emergency Committee, and participation in independent assessments of core capacities.	Who: CSOs, academics, and other interested partners in collaboration with the WHO Why: Civil society is already deeply engaged in caring for communities, monitoring governments, and holding stakeholders to account. CSOs should be engaged as productive partners.	WHO administrative action
Linking the IHR with the PIP Framework and Closing Gaps in the Governance of Sample Sharing and Equitable Access to Vaccines and Treatments	Harmonize the IHR and PIP Framework, enhance governance of sample sharing and equitable access, and integrate mechanisms to address biosecurity challenges associated with genomic sequencing.	Who: WHA Member States Why: The IHR do not address sample sharing, PIP does not apply to any agent beyond novel influenzas, and neither agreement addresses genomic sequencing. This leaves major gaps in the global governance of disease.	WHA understandings or addition of an annex to the IHR
One Health Approach	Adapt the IHR to take an explicit One Health approach to addressing global health security challenges.	Who: The WHO and WHA Member States in collaboration with the FAO and the OIE Why: Most emerging infectious disease threats are zoonotic, and effectively addressing them requires a One Health approach that fully integrates animal and human health systems. The benefits include better detection and response and confronting the major challenge of antimicrobial resistance.	WHA understandings and operational guidance from the WHO, OIE, and FAO